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Abstract Background Illness-related costs incurred by patients constitute a severe economic burden for households especially in low-income countries. High household costs of illness lead to impoverishment; they impair affordability and equitable access to health care and consequently hamper tuberculosis (TB) control. So far, no study has investigated patient costs of TB in the former Soviet Union. Methods All adult new pulmonary TB cases enrolled into the DOTS program in 12 study districts during the study period were enrolled. Medical and non-medical expenditure as well as loss of income were quantified in two interviews covering separate time periods. Costs of different items were summed up to calculate total costs. For missing values, multiple imputation was applied. Results A cohort of 204 patients under DOTS, 114 men and 90 women, participated in the questionnaire survey. Total illness costs of a TB episode averaged $1053 (c. $4900 purchasing power parity, PPP), of which $292, $338 and $422 were encountered before the start of treatment, during intensive phase and in continuation phase, respectively. Costs per month were highest before the start of treatment ($145) and during intensive phase ($153) and lower during continuation phase ($95). These differences were highly significant (paired t-test, p < 0.0005 for both comparisons). Conclusions The illness-related costs of an episode of TB exceed the per capita GDP of $1600 PPP about two-and-a-half times. Hence, these costs are catastrophic for concerned households and suggest a high risk for impoverishment. Costs are not equally spread over time, but peak in early stages of treatment, exacerbating the problem of affordability. Mitigation strategies are needed in order to control TB in Tajikistan and may include social support to the patients as well as changes in the management of TB cases. These mitigation strategies should be timed early in treatment when the cost burden is highest.

Abstract Background In Tajikistan it is estimated that out of pocket payments constitute two-thirds of all health spending with high proportions of these contributions through informal payments. As a consequence, access to basic care is a major concern particularly among the most needy and vulnerable groups. This article evaluates accessibility of prescription medicines and patient expenditures for primary care services in two rural districts of Tajikistan. Methods 901 patients aged 18 years or above who had accessed primary care facilities were interviewed, using a questionnaire based on questions regarding patient's experience of visiting the health facility. To group respondents by socio-economic status, an asset index was created using principal component analysis of the information included in the questionnaires. Results 76.7% of patients were prescribed a medicine during the visits and more than 83% of them managed to obtain it. Patients spent on average US$ 9.3 on medicines, with wide variation among socio-economic groups. Around 45% of patients paid the Family Doctor. Additionally, over 41% of patients in the highest socioeconomic quintile were referred to a specialist, while only 29% of the poorest 40%. Conclusion This survey showed that there are financial barriers potentially inactivating utilization of basic services. These barriers can only be reduced by mobilizing more public resources to fund the health sector, providing incentives for family doctors to stop requiring payments from patients, and increasing the availability of prescription drugs in PHC facilities.

Background: In Tajikistan it is estimated that out of pocket payments constitute two-thirds of all health spending with high proportions of these contributions through informal payments. As a consequence, access to basic care is a major concern particularly among the most needy and vulnerable groups. This article evaluates accessibility of prescription medicines and patient expenditures for primary care services in two rural districts of Tajikistan.Methods: 901 patients aged 18 years or above who had accessed primary care facilities were interviewed, using a questionnaire based on questions regarding patient's experience of visiting the health facility. To group respondents by socio-economic status, an asset index was created using principal component analysis of the information included in the questionnaires.Results: 76.7% of patients were prescribed a medicine during the visits and more than 83% of them managed to obtain it. Patients spent on average US$ 9.3 on medicines, with wide variation among socio-economic groups. Around 45% of patients paid the Family Doctor. Additionally, over 41% of patients in the highest socioeconomic quintile were referred to a specialist, while only 29% of the poorest 40%.Conclusion: This survey showed that there are financial barriers potentially inactivating utilization of basic services. These barriers can only be reduced by mobilizing more public resources to fund the health sector, providing incentives for family doctors to stop requiring payments from patients, and increasing the availability of prescription drugs in PHC facilities. [ABSTRACT FROM AUTHOR]

The expanding number of rare immunodeficiency syndromes offers an opportunity to understand key genes that support immune defense against infectious diseases. However, analysis of these in patients is complicated by their treatments and comorbid infections, requiring the use of mouse models for detailed investigations. We developed a mouse model of DOCK2 immunodeficiency and herein demonstrate that these mice have delayed clearance of herpes simplex virus type 1 (HSV-1) infections. We also uncovered a critical, cell-intrinsic role of DOCK2 in the priming of antiviral CD8+ T cells and in particular their initial expansion, despite apparently normal early activation of these cells. When this defect was overcome by priming in vitro, DOCK2-deficient CD8+ T cells were surprisingly protective against HSV-1 disease, albeit not as effectively as wild-type cells. These results shed light on a cellular deficiency that is likely to impact antiviral immunity in DOCK2-deficient patients., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Metabolic surgery has been on the rise over the last 2 decades. As more literature has been being published regarding its efficacy in treating metabolic syndrome as well as advancements in surgical training and safety rise with it, metabolic surgery will in no doubt continue to increase in prevalence. Concomitantly, the prevalence of esophageal cancer is increasing. We present two cases of patients who are status post sleeve gastrectomy and require esophagectomy. These patients do not have the availability of a gastric conduit, and colon interposition graft was planned for their reconstructions. We here review the two unique case scenarios as well as an overview of colon interposition technique and workup considerations. The need this reconstruction technique will likely increase in the years to come and metabolic surgery and esophageal cancer both continue to rise., (© 2022. The Society for Surgery of the Alimentary Tract.)

The diversity of circulating human B cells is unknown. We use single-cell RNA sequencing (RNA-seq) to examine the diversity of both antigen-specific and total B cells in healthy subjects and malaria-exposed individuals. This reveals two B cell lineages: a classical lineage of activated and resting memory B cells and an alternative lineage, which includes previously described atypical B cells. Although atypical B cells have previously been associated with disease states, the alternative lineage is common in healthy controls, as well as malaria-exposed individuals. We further track Plasmodium-specific B cells after malaria vaccination in naive volunteers. We find that alternative lineage cells are primed after the initial immunization and respond to booster doses. However, alternative lineage cells develop an atypical phenotype with repeated boosts. The data highlight that atypical cells are part of a wider alternative lineage of B cells that are a normal component of healthy immune responses., Competing Interests: Declaration of interests S.C., N.K., B.K.L.S., and S.L.H. are salaried employees of Sanaria, the developer and owner of PfSPZ Vaccine and the investigational new drug (IND) application sponsor of the clinical trials. S.L.H. and B.K.L.S. have a financial interest in Sanaria. All other authors declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Atypical memory B cells (aMBCs) are found in elevated numbers in individuals exposed to malaria. A key question is whether malaria induces aMBCs as a result of exposure to Ag, or non-Ag-specific mechanisms. We identified Plasmodium and bystander tetanus toxoid (TT) specific B cells in individuals from areas of previous and persistent exposure to malaria using tetramers. Malaria-specific B cells were more likely to be aMBCs than TT-specific B cells. However, TT-specific B cells from individuals with continuous exposure to malaria were more likely to be aMBCs than TT-specific B cells in individuals from areas where transmission has ceased. Finally, sequences of BCRs specific for a blood stage malaria-Ag were more highly mutated than sequences from TT-specific BCRs and under strong negative selection, indicative of ongoing antigenic pressure. Our data suggest both persistent Ag exposure and the inflammatory environment shape the B-cell response to malaria and bystander Ags., (© 2020 The Authors. European Journal of Immunology published by WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

B-cell and antibody responses to Plasmodium spp., the parasite that causes malaria, are critical for control of parasitemia and associated immunopathology. Antibodies also provide protection to reinfection. Long-lasting B-cell memory has been shown to occur in response to Plasmodium spp. in experimental model infections, and in human malaria. However, there are reports that antibody responses to several malaria antigens in young children living with malaria are not similarly long-lived, suggesting a dysfunction in the maintenance of circulating antibodies. Some studies attribute this to the expansion of atypical memory B cells (AMB), which express multiple inhibitory receptors and activation markers, and are hyporesponsive to B-cell receptor (BCR) restimulation in vitro. AMB are also expanded in other chronic infections such as tuberculosis, hepatitis B and C, and HIV, as well as in autoimmunity and old age, highlighting the importance of understanding their role in immunity. Whether AMB are dysfunctional remains controversial, as there are also studies in other infections showing that AMB can produce isotype-switched antibodies and in mouse can contribute to protection against infection. In light of these controversies, we review the most recent literature on either side of the debate and challenge some of the currently held views regarding B-cell responses to Plasmodium infections., (© 2019 The Authors. Immunological Reviews published by John Wiley & Sons Ltd.)

Mycoplasma mycoides subspecies mycoides (Mmm) adhesion is tissue and host specific. Inhibition of adhesion will prevent Mmm from binding to lung cells and hence prevent colonization and disease. The aim of this study was to develop a panel of Mmm monoclonal antibodies against Mmm and use these antibodies to investigate their inhibitory effect on the adherence of Mmm to bovine lung epithelial cells (BoLEC), and to further identify an antigen to any of the inhibitory antibodies. Thirteen anti-Mycoplasma mycoides subsp. mycoides (AMMY) monoclonal antibodies (mAbs) inhibited adhesion by at least 30% and ten of the mAbs bound to multiple bands on Western blots suggesting that the antibodies bound to proteins of variable sizes. AMMY 10, a previously characterized Mmm- capsular polysaccharide (CPS) specific antibody, inhibited growth of Mmm in vitro and also caused agglutination of Mmm total cell lysate. AMMY 5, a 2-oxo acid dehydrogenase acyltransferase (Catalytic domain) (MSC&#95;0267) specific antibody, was identified and polyclonal rabbit serum against recombinant MSC&#95;0267 blocked adhesion of Mmm to BoLEC by 41%. Antigens recognized by these antibodies could be vaccine candidate(s) and should be subsequently tested for their ability to induce a protective immune response in vivo., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To compare long-term survival rates of patients with first, primary, clinical stage IA nonsmall cell lung cancer from a large cohort undergoing computed tomography screening with and without mediastinal lymph node resection (MLNR) under an Institutional Review Board-approved common protocol from 1992 to 2014., Background: Assessing survival differences of patients with and without MLNR manifesting as solid and subsolid nodules., Methods: Long-term Kaplan-Meier (K-M) survival rates for those with and without MLNR were compared and Cox regression analyses were used to adjust for demographic, computed tomography, and surgical covariates., Results: The long-term K-M rates for 462 with and 145 without MLNR was 92% versus 96% (P = 0.19), respectively. For 203 patients with a subsolid nodule, 151 with and 52 without MLNR, the rate was 100%. For the 404 patients with a solid nodule, 311 with and 93 without MLNR, the rate was 87% versus 94% (P = 0.24) and Cox regression showed no statistically significant difference (P = 0.28) when adjusted for all covariates. Risk of dying increased significantly with increasing decades of age (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.4-3.8), centrally located tumor (HR 2.5, 95% CI 1.2-5.2), tumor size 21 to 30 mm (HR 2.7, 95% CI 1.2-6.0), and invasion beyond the lung stroma (HR 3.0, 95% CI 1.4-6.1). For the 346 patients with MLNR, tumor size was 20 mm or less; K-M rates for the 269 patients with and 169 patients without MLNR were also not significantly different (HR 2.1, P = 0.24)., Conclusions: It is not mandatory to perform MLNR when screen-diagnosed nonsmall cell lung cancer manifests as a subsolid nodule.

The current control method for contagious bovine pleuropneumonia (CBPP) in Africa is vaccination with a live, attenuated strain of Mycoplasma mycoides subsp. mycoides (Mmm). However, this method is not very efficient and often causes serious adverse reactions. Several studies have attempted to induce protection using inactivated mycoplasma, but with widely contradictory results. Therefore, we compared the protective capacity of the live T1/44 vaccine with two inactivated preparations of Mmm strain Afadé, inoculated with an adjuvant. Protection was measured after a challenge with Afadé. The protection levels were 31%, 80.8% and 74.1% for the formalin-inactivated, heat-inactivated and live attenuated preparations, respectively. These findings indicate that low doses of heat-inactivated Mmm can offer protection to a level similar to the current live attenuated (T1/44) vaccine formulation., (Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Mycoplasma mycoides subsp. mycoides (Mmm) is the causative agent of contagious bovine pleuropneumonia (CBPP), a respiratory disease of cattle, whereas the closely related Mycoplasma mycoides subsp. capri (Mmc) is a goat pathogen. Cyto-adherence is a crucial step in host colonization by mycoplasmas and subsequent pathogenesis. The aim of this study was to investigate the interactions between Mmm and mammalian host cells by establishing a cyto-adherence flow cytometric assay and comparing tissue and species specificity of Mmm and Mmc strains., Results: There were little significant differences in the adherence patterns of eight different Mmm strains to adult bovine lung epithelial cells. However, there was statistically significant variation in binding to different host cells types. Highest binding was observed with lung epithelial cells, intermediate binding with endothelial cells and very low binding with fibroblasts, suggesting the presence of effective adherence of Mmm on cells lining the airways of the lung, which is the target organ for this pathogen, possibly by high expression of a specific receptor. However, binding to bovine fetal lung epithelial cells was comparably low; suggesting that the lack of severe pulmonary disease seen in many infected young calves can be explained by reduced expression of a specific receptor., Conclusions: Mmm bound with high efficiency to adult bovine lung cells and less efficiently to calves or goat lung cells. The data show that cyto-adherence of Mmm is species- and tissue- specific confirming its role in colonization of the target host and subsequent infection and development of CBPP.

Background: A regional quality improvement effort does not exist for thoracic surgery in the United States. To initiate the development of one, we sought to describe temporal trends and hospital-level variability in associated outcomes and costs of pulmonary resection in Washington (WA) State., Methods: A cohort study (2000-2011) was conducted of operated-on lung cancer patients. The WA State discharge database was used to describe outcomes and costs for operations performed at all nonfederal hospitals within the state., Results: Over 12 years, 8,457 lung cancer patients underwent pulmonary resection across 49 hospitals. Inpatient deaths decreased over time (adjusted p-trend=0.023) but prolonged length of stay did not (adjusted p-trend=0.880). Inflation-adjusted hospital costs increased over time (adjusted p-trend<0.001). Among 24 hospitals performing at least 1 resection per year, 5 hospitals were statistical outliers in rates of death (4 lower and 1 higher than the state average), and 13 were outliers with respect to prolonged length of stay (7 higher and 6 lower than the state average) and costs (5 higher and 8 lower than the state average). When evaluated for rates of death and costs, there were hospitals with fewer deaths/lower costs, fewer deaths/higher costs, more deaths/lower costs, and more deaths/higher costs., Conclusions: Variability in outcomes and costs over time and across hospitals suggest opportunities to improve the quality and value of thoracic surgery in WA State. Examples from cardiac surgery suggest that a regional quality improvement collaborative is an effective way to meaningfully and rapidly act upon these opportunities., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Surgical management is a critical component of computed tomography (CT) screening for lung cancer. We report the results for US sites in a large ongoing screening program, the International Early Lung Cancer Action Program (I-ELCAP)., Methods: We identified all patients who underwent surgical resection. We compared the results before (1993-2005) and after (2006-2011) termination of the National Lung Screening Trial to identify emerging trends., Results: Among 31,646 baseline and 37,861 annual repeat CT screenings, 492 patients underwent surgical resection; 437 (89%) were diagnosed with lung cancer; 396 (91%) had clinical stage I disease. In the 54 (11%) patients with nonmalignant disease, resection was sublobar in 48 and lobectomy in 6. The estimated cure rate based on the 15-year Kaplan-Meier survival for all 428 patients (excluding 9 typical carcinoids) with lung cancer was 84% (95% confidence interval [CI], 80%-88%) and 88% (95% CI, 83%-92%) for clinical stage I disease resected within 1 month of diagnosis. Video-assisted thoracoscopic surgery and sublobar resection increased significantly, from 10% to 34% (P < .0001) and 22% to 34% (P = .01) respectively; there were no significant differences in the percentage of malignant diagnoses (90% vs 87%, P = .36), clinical stage I (92% vs 89%, P = .33), pathologic stage I (85% vs 82%, P = .44), tumor size (P = .61), or cell type (P = .81)., Conclusions: The frequency and extent of surgery for nonmalignant disease can be minimized in a CT screening program and provide a high cure rate for those diagnosed with lung cancer and undergoing surgical resection., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: A single randomized trial established lobectomy as the standard of care for the surgical treatment of early-stage non-small cell lung cancer. Recent advances in imaging/staging modalities and detection of smaller tumors have once again rekindled interest in sublobar resection for early-stage disease. The objective of this study was to compare lung cancer survival in patients with non-small cell lung cancer with a diameter of 30 mm or less with clinical stage 1 disease who underwent lobectomy or sublobar resection., Methods: We identified 347 patients diagnosed with lung cancer who underwent lobectomy (n = 294) or sublobar resection (n = 53) for non-small cell lung cancer manifesting as a solid nodule in the International Early Lung Cancer Action Program from 1993 to 2011. Differences in the distribution of the presurgical covariates between sublobar resection and lobectomy were assessed using unadjusted P values determined by logistic regression analysis. Propensity scoring was performed using the same covariates. Differences in the distribution of the same covariates between sublobar resection and lobectomy were assessed using adjusted P values determined by logistic regression analysis with adjustment for the propensity scores. Lung cancer-specific survival was determined by the Kaplan-Meier method. Cox survival regression analysis was used to compare sublobar resection with lobectomy, adjusted for the propensity scores, surgical, and pathology findings, when adjusted and stratified by propensity quintiles., Results: Among 347 patients, 10-year Kaplan-Meier for 53 patients treated by sublobar resection compared with 294 patients treated by lobectomy was 85% (95% confidence interval, 80-91) versus 86% (confidence interval, 75-96) (P = .86). Cox survival analysis showed no significant difference between sublobar resection and lobectomy when adjusted for propensity scores or when using propensity quintiles (P = .62 and P = .79, respectively). For those with cancers 20 mm or less in diameter, the 10-year rates were 88% (95% confidence interval, 82-93) versus 84% (95% confidence interval, 73-96) (P = .45), and Cox survival analysis showed no significant difference between sublobar resection and lobectomy using either approach (P = .42 and P = .52, respectively)., Conclusions: Sublobar resection and lobectomy have equivalent survival for patients with clinical stage IA non-small cell lung cancer in the context of computed tomography screening for lung cancer., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: To identify characteristic computed tomographic (CT) and computer-derived features of hamartomas manifesting as small pulmonary nodules., Methods: Individuals with a diagnosis of hamartoma were identified among participants in the International Early Lung Cancer Action Program and were included if there thin section CT images that included the entire nodule. The CT findings were reviewed to determine the nodule consistency (solid, part-solid, nonsolid), nodule diameter (average of length and width), shape (round, lobulated, neither) and edge (smooth, not smooth). Computer measures of nodule compactness, sphericity, surface regularity and gradient (change in gray-scale between the nodule and the surrounding parenchyma) were determined. Volume doubling time (VDT) was also determined for those with at least two scans with similar imaging acquisitions., Results: A total of 21 cases of hamartomas that had histologic or cytologic confirmation were identified. The median age was 60 and 12 (57%) were men. Average diameter was 10.7 mm (5-20.7 mm). All were solid in consistency and were described by the radiologist as having either round or lobulated shape with a smooth edge. None had pathognomonic radiologic findings for hamartoma. Computer measures demonstrated that all were compact and spherical, with a regular surface and a sharp margin between the nodule and surrounding parenchyma. Of nine on whom the VDT could be calculated, eight had VDTs longer than 450 days., Conclusion: Both radiologist and computer derived features of small hamartomas suggest a consistent presentation for these lesions which may be helpful in distinguishing them from other types of nodules., (Copyright © 2011. Published by Elsevier Inc.)

Background: The relationship between body position and the gastroesophageal junction (GEJ) has been subject to intense interest in its role in gastroesophageal reflux disease (GERD). Few studies have looked at the position related changes of the gastroesophageal valve (GEV) in asymptomatic individuals., Purpose: To define the normal physiology of the GEJ in left lateral decubitus (LLD) and upright position in asymptomatic individuals., Methods: Ten healthy asymptomatic volunteers with no previous history of GERD were recruited. Patients underwent upper endoscopy, with detailed observation and grading of the gastroesophageal valve (Hill Grade 1-4; 1 = normal closed valve, 4 = open valve, associated hiatus hernia) in both LLD and upright positions. Patients underwent high resolution manometry, with wet swallows performed in LLD and upright positions. A Bravo pH probe was placed in the distal esophagus and used to perform 48-h pH studies in all patients., Results: Four out of 10 patients were noted to have abnormal 48 h pH studies (DeMeester score >14.7). Endoscopically, there was an overall increase in mean Hill Grade when patients were moved from LLD to upright position (1.6, 2.3, p = 0.04, respectively), with no significant differences between normal and abnormal pH patients. In the abnormal pH group, on endoscopy, 75% were found to have prolonged opening of the GEV on passive retroflexed observation in LLD position, compared with 16.7% of normal pts (p = 0.1). Manometrically, this was correlated with lower mean LES resting pressures and shorter intra-abdominal LES length for the abnormal pH patients in all positions compared to normals. As well, for the abnormal pH group, LESP trended down slightly when moved from LLD to upright position (11.2 vs. 8.0 mmHg, respectively; p = 0.3)., Conclusions: In normal individuals, the GEV exhibits a temporary weakening when moved from LLD to upright position. However, the normal GEV is able to maintain LESP in upright position. In contrast, in patients with early GERD, a greater degree of valve incompetence at the GEJ is seen. This is correlated manometrically with a trend toward shorter LES length and lower LESP when moved from LLD to upright position. This upright incompetence of the GEV may be one of the earliest manifestations in GERD. Proper evaluation of the GEV should include endoscopic evaluation in both recumbent and upright positions. Further studies are needed to evaluate the corresponding changes of the GEV in varying degrees of symptomatic GERD.

Background: Malignant pleural mesothelioma is a fatal disease. The optimal modality and sequence of therapy are controversial. We analyzed the outcomes of a cohort of mesothelioma patients treated with induction chemotherapy, followed by extrapleural pneumonectomy (EPP) and adjuvant radiation., Methods: The study comprised a retrospective cohort of 46 patients treated with induction chemotherapy, followed by EPP, during a 10-year period. Of these, 24 completed adjuvant external beam radiotherapy (EBRT), and 14 had intensity-modulated radiotherapy (IMRT)., Results: Mean follow-up was 20.6 months (range, 0.5 to 75 months). Operative mortality after EPP was 4.3% (n = 2). Pathologic stage was p0, 4.3%; pII, 23.9%; pIII, 56.5%; and pIV, 15.2%. Median overall survival was 24 months. On univariate analysis and Cox proportional hazards model, only nodal metastases (hazard ratio, 3.7; 95% confidence interval, 1.6 to 8.7; p = 0.002) was a significant predictor of survival. First site of recurrence was local in 12, the contralateral chest in 5, abdominal in 8, and distant in 5. The incidence of local recurrence was 14.3% with IMRT vs 41.7% with EBRT (p = 0.03). The time to local recurrence with the use of IMRT was 12 months vs 7 for EBRT (p = 0.19)., Conclusions: Induction chemotherapy, followed by EPP and adjuvant radiotherapy for selected patients with mesothelioma, is safe, with acceptable operative mortality. Adjuvant IMRT may be more effective in terms of local control than EBRT.

Background: Cancer and sarcoidosis have been associated in several small case series. This association makes the cancer patient with lymphadenopathy a diagnostic dilemma: malignant involvement of the lymph nodes is common, but benign diagnoses are possible and must be considered., Methods: We conducted a retrospective chart review of all patients with a diagnosis of sarcoidosis or mediastinal adenopathy who underwent mediastinoscopy at the Swedish Medical Center and Cancer Institute from 2004 to 2008., Results: Five hundred sixty-five mediastinoscopies were performed. There were 41 cases of biopsy-proven sarcoidosis. Twenty-one cases of sarcoidosis were diagnosed after a diagnosis of cancer. No primary cancer type was predominant. Cancers were of all stages, with and without lymph node involvement. The most common positron emission tomography combined with a computed tomography scan (PET CT) finding was bilateral hilar adenopathy with symmetric standardized uptake values (SUV) in the 4 to 15 range (62%), but many other PET CT patterns were present., Conclusions: Hypermetabolic lymphadenopathy on staging or surveillance imaging presents a diagnostic dilemma. Sarcoidosis must be considered in the differential diagnosis of patients with a history of malignancy who develop lymphadenopathy. It is imperative to obtain a tissue diagnosis before instituting therapy for presumed cancer recurrence.

Background: Sterile talc is currently the agent of choice for pleurodesis. Its success rate is excellent, and talc is generally well tolerated. However, a recent experience with fulminant pneumonitis following talc pleurodesis prompted a review of our experience., Methods: A retrospective review of patients undergoing talc pleurodesis at our institution between December 1993 and December 1997 was performed, documenting respiratory and other complications. Statistical analysis was performed using Student's t test and Pearson correlations., Results: Seventy-eight patients received 89 talc pleurodesis procedures. Respiratory complications or death occurred in 33%; 9% of patients developed adult respiratory distress syndrome. There was no statistical difference in outcomes between patient groups, methods of application, or talc dosages utilized., Conclusions: This series revealed a significantly higher rate of serious complications than that reported in the current literature, without implicating a clear reason for these outcomes. Our data raise questions about the safety of talc pleurodesis.

Background: This study was performed to confirm the presence and significance of a gastroesophageal flap valve., Methods: The pressure gradient needed to induce reflux across the gastroesophageal junction and the level of a high-pressure zone were determined in 13 cadavers. On inspection in the cadavers, a mucosal flap valve at the entrance of the esophagus into the stomach was seen through a gastrostomy. This valve was deficient or absent in cadavers with a hiatal hernia. The valve was inspected in controls and in patients with reflux with a retroflexed endoscope., Results: In cadavers with no hiatal hernia, a gradient across the gastroesophageal junction was present in nearly all cadavers. The gradient could be increased by surgically accentuating the valve without a concomitant rise in pressure in the high-pressure zone. Reduction of the hiatal hernia in the cadaver and anchoring of the gastroesophageal junction to the normal attachment to the preaortic fascia restored the valve and the gradient as seen through a gastrostomy. Control subjects had a prominent fold of tissue that extended 3 to 4 cm along the lesser curve of the stomach and tightly grasped the shaft of the endoscope. This was diminished or absent in reflux patients. Inspection of the valve in control subjects and subjects with reflux allowed for a grading system with Grades I through IV. This grading system was applied to a cohort of patients with and without reflux. The appearance of the flap valve was a better predictor of the presence or absence of reflux than was lower esophageal sphincter pressure. Endoscopic viewing of the valve during surgery can confirm that a competent valve has been reconstructed., Conclusions: Grading of the gastroesophageal valve is simple, reproducible, and offers useful information in the evaluation of patients with suspected reflux undergoing endoscopy.

Gastroesophageal reflux disease, with its attendant symptoms and complications of heartburn, esophagitis, dysphagia, and upper gastrointestinal bleeding, is the most common disorder of the upper gastrointestinal tract. The open Hill repair, which has been utilized in more than 2000 patients, is best defined as restoration of the anti-reflux barrier. The anti-reflux barrier includes the gastroesophageal valve, lower esophageal sphincter, and diaphragm. The Hill repair has now been done laparoscopically in 17 patients (10 men and 7 women) who have been entered into a detailed protocol, including pre-operative evaluation, intra-operative monitoring, and post-operative evaluation. Results have been excellent, with correction of reflux in all patients. Duration of follow-up ranges from 1 to 18 months, with a mean of 10.5 months. No mortality or serious complications have occurred. Extensive post-operative testing in 13 patients, including complete symptom evaluation, standard acid reflux testing, and 24-hour pH monitoring, has shown no recurrence of reflux; lower esophageal sphincter pressure has been restored to a mean of 28 mm Hg, and gastroesophageal valve status to grade 1. Because the laparoscopic procedure is similar to the open Hill repair, expectations for good long-term results are very high.

Enzymatic debridement of the pleural cavity for retained hemothorax or empyema is a frequently overlooked option. Thirteen of fourteen patients (93%) with retained pleural collections underwent successful enzymatic debridement and tube drainage with purified streptokinase injections. The average increase in chest tube output following streptokinase injections was 158%. No significant adverse reactions occurred. One patient required thoracotomy when streptokinase therapy failed. Two others had successful resolution of their pleural collections but required thoracotomy for other indications. There were two deaths (14%), which were unrelated to the use of streptokinase or residual empyema. Intrapleural streptokinase is a safe, effective means of removing retained proteinaceous collections in the pleural space. It is a useful adjunct to chest tube drainage and may obviate the need for more invasive procedures.

A technetium-labeled monoclonal antibody was administered to 52 patients with non-small cell lung carcinoma, either to stage the mediastinum preoperatively or to detect distant metastases. Results from planar and tomographic imaging are compared to CT and histologic confirmation. Differences in detection rates and predictive values between imaging modalities are discussed. The authors conclude that imaging with a technetium-labeled monoclonal antibody is safe and accurate and may be useful for staging patients with either operable or inoperable non-small cell lung cancer.

With a reassessment of the antireflux barrier, we are gaining a better appreciation of the components of the barrier and their importance in preventing reflux. The GE valve in particular appears to play a key role in preventing reflux. With better understanding of the anatomy and function of the GE barrier, we should do a better job, both medically and surgically. The knowledge and new technology that are available should allow the surgeon to perform antireflux surgery with 95% good to excellent results with a minimum of morbidity. As our 15 to 20 year follow-up with a mean of 17.8 years shows, these good results will last over the long term. These observations should give the gastroenterologist confidence that antireflux surgery is highly effective for those patients who fail medical management.